McBride, John NEW YORK STATE DEPARTMENT OF HEALTH Burial • Transit Permit
Vital Records Section
Name First Middle Last Sex
1 Date of Death Age q If Veteran of U.S.Armed Forces,
( 41'-0%J 0 i o� 10 War or Dates
,' Plac ath Hospital, Institution or
Ci , Town o Villagea Street Address
la
0 Manner o Death Natural Cause cc ent 0 Homicide Q Suicide Undetermined Pending
:i �1 Circumstances Investigation
Medical Certifiertii Name • Title
IftiO s /c. bi soc.0/6� n4 O
Address CCam�,"" �/� /J{� j /� /{7 Fa (J
r Death Cificate Filed D �Number ✓ Register Number
-<s City own • Village S "7
Date Cemetery or Crematory �^
❑Burial 0/ -0 3--/a -e.i L' e �/ [ 7-ekvt4,
Address •
ACremation 64ee,cis k rAit� a c"y, 6.`� �°Cf�
Date - Place Removed
ZI—I❑Removal • and/or Held
and/or Address
g Hold
0 Date Point of
Q Transportation Shipment
D by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•::? Reinterment Date Cemetery Address
Permit Issued to yy�� // � Registration Number
'< Name of Funeral Home /E.7-t,1� /� ic:,,,e /�1 (;'!/ ?U
im Address
1r' Z:,--, re-- SDK C� Ni Y� /v.,v i�8�1
_r.> Name of Funeral Firm ing Disposition or to Morn
Remains are Shipped, If Other than Above
46 Address •
Iti
IX
ei Permission is hereby granted to dispose of the huma remains described above as indicated.
~" Date Issued 1 I hU! Registrar of Vital Statistics G� et . C-6 ass
A (signature)
„` District Number` (EiE ..9 c m Place \ [) �,r�
I certify that the remains of the decedent identified al3ove were disposed of in accord nce ith this permit on:
F
Date of Disposition t- 5't2 Place of Disposition Zukli-,1 C .4-ar i,-n_
2 (address)
CD
rt (section) d - (lot nurter) (grave number)
0Name of Sexton or Person in Char a of Premises r,,+/P r J om,utt
(please print)
U. Signatu?e atfL The Cee- 'A IA-d a_
(over)
DOH-1555 (9/98)